Healthcare Provider Details

I. General information

NPI: 1649661711
Provider Name (Legal Business Name): MATTERS OF THE SPIRIT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/11/2015
Last Update Date: 09/12/2023
Certification Date: 09/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12645 W BURLEIGH RD STE 19
BROOKFIELD WI
53005-3102
US

IV. Provider business mailing address

12645 W BURLEIGH RD STE 19
BROOKFIELD WI
53005-3102
US

V. Phone/Fax

Practice location:
  • Phone: 262-432-0670
  • Fax: 262-475-0412
Mailing address:
  • Phone: 262-432-0670
  • Fax: 262-475-0412

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: TINA SANFORD
Title or Position: DIRECTOR
Credential:
Phone: 262-432-0670